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TITLE: THE MANAGEMENT OF ACUTE UPPER AIRWAY OBSTRUCTION
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: July 12, 1994
FACULTY: RONALD W. DESKIN, M.D.
DATABASE ADMINISTRATOR: Melinda McCracken, M.S.
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"This material was prepared for the Postgraduate Training
Program of the UTMB Department of Otolaryngology/Head and Neck Surgery
and was not intended for clinical use in its present form. It was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect
to its accuracy, completeness, or timeliness. The material does not
necessarily reflect the current or past opinions of members of the UTMB
faculty and should not be used for purposes of diagnosis or treatment
without consulting appropriate literature sources and informed professional
opinion."
I. Infection in the Pediatric Airway
A. Location
1. Supraglottic
2. Subglottic
3. Tracheitis
B. Why Are Symptoms So Severe?
1. Size of the airway
2. Loose submucosa
3. Rigid subglottic i.e., 1mm of swelling equals 35% decrease
in circumference
II. History
A. Onset
1. How presented?
2. Duration?
3. Progressive?
4. History of foreign body?
B. Associated Illness
1. URI
2. Cough
3. Medications
C. Allergy
1. Penicillin
2. Asthma
3. Other meds
D. Associated Symptoms
1. Cough
2. Hoarseness, muffled voice
3. Sputum
4. Cyanosis
5. Vomiting
6. Drooling
7. Fever
8. Dysphagia, throat pain
E. Time and Nature of Last Oral Intake
F. Family History
G. Other Conditions/Respiratory, Cardiovascular, Neurologic
III. Physical Examination
A. Cyanosis
B. Position
C. Anxiety
D. Drooling
E. Describe Stridor
F. Retraction
G. Voice of Cry
H. Respiratory rate and depth
I. Pulse and temperature
J. Auscultation
IV. Decide on Consultants and Call Them
V. Physician Stays with Child
A. Parent's lap
B. Sitting on stretcher
C. Do not lay down
D. No upsetting procedure such as IV, ABG, Blood Culture, Throat
Culture or Throat Exam
E. Keep room traffic down
VI. Initial Treatment
A. Cool Mist
B. Vaponefrin
C. If arrest occurs - positive pressure with mask and oxygen
VII. Triage Nurse
A. Calls Consultants
B. Notifies OR and ICU
C. Hold Elevator
D. Get emergency equipment ready in the emergency room
E. Proper scopes
F. ETT-appropriate size and two sizes smaller
G. McGill forceps
H. Tonsil Suction
I. Succinyl Choline
J. Monitor Child
K. Act as parent if parents are upsetting child or cannot function
VIII. Disposition
A. Avoid unnecessary delay in ER
B. Radiology?
C. Portable X-ray?
D. Operating room - set up and ready
E. Direct laryngoscopes - intubating type
F. Bronchoscope size 3 and 4
G. Tracheotomy set
H. Foreign Body instruments
IX. Transfer to OR
A. Induction with mask - gentle
B. IV after asleep
C. Laryngoscopy
D. Oral ETT - Change to nasal tube
E. Size smaller than usual for age
F. Throat culture, blood culture and LP?
X. PICU
A. Sedate and restrain
B. Humidified oxygen with unencumbered ETT
C. Frequent saline and suction
D. NPO - NG tube
E. Antibiotics for 10 days - 7 days IV
F. If CSF positive - 10 to 14 days IV
G. AMP/chlor or 3rd generation cephalosporin
H. Extubate 48 hours
I. Criteria/afebrile, improved condition overall, leak around ETT
J. in PICU? in OR if above uncertain
K. NPO and PICU X 8 hours
L. Transfer to floor
M. Prophylaxis for contacts - AAP common I.D.
XI. Croup - LTB
A. DL and NTT, if ( some prefer tracheotomy):
-Severe stridor needing epi treatment increasingly frequent
-cyanosis unrelieved by oxygen
-pulse consistently greater than 180
steroids usually given before this point to try to avoid
intubation (1mg per kg of decadron)
B. PICU Care as with Epiglottis
1. Rare to be able to extubate sooner than 3 to 4 days
2. Decadron, 1 mg per kg 4 hours prior to extubation
XII. Bacterial Tracheitis
A. Croup Symptoms - but poor response to treatment
B. Older Child
C. 50% Staph Aureus
D. X-ray - scalloping of tracheal walls
E. Treatment
1. Bronchoscopy to remove crusts
2. IV Fluid
3. Humidification
4. Anti-Staph antibiotic
5. ETT, trach rarely
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BIBLIOGRAPHY
1. Apley, John: "The Infant with Stridor," Arch. Dis. Child.
28:423, 1953.
2. "Acute Epiglottitis in Children," New Eng. J. of Med. 258:870,
1958.
3. Holinger, Paul: "Pediatric Laryngology," Otolaryngologic Clinic of
North America. 625-37, Oct. 1970.
4. Gross, Chas: "Treatment of Upper Airway Obstruction in Children,"
Otolaryngologic Clinics of North America. 157-65, Feb. 1977.
5. Bluestone & Stool: "Pediatric Otolaryngology," Vol. II. 1152-1156-1259,
W.B. Saunders & Co., 1990.
6. Ashcraft, C. & Steele, Russell: "Epiglottitis - A Pediatric Emergency"
J. of Resp. Disease. 48-60, July 1988.
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Guidelines for the Care of Patients Suspected of
Having Acute Epiglottitis at Brackenridge Hospital
All patients who are seriously suspected to have acute epiglottitis, either on
the basis of clinical history and physical examination alone or on the basis
of radiographic findings, shall be evaluated jointly by a team consisting of
three services: Pediatrics, ENT and Anesthesia. If the diagnosis is strongly
suspected on the basis of clinical history and physical findings alone,
especially if the patient does not appear stable, the team should be assembled
as rapidly as possible. If the diagnosis is less certain and the patient's
condition allows, a soft tissue lateral radiograph of the neck should be
obtained. If the diagnosis is supported by radiographic findings, then the
team should be assembled immediately. During the initial evaluation of any
patient suspected of having epiglottitis who is having respiratory distress,
several precautions are necessary: supplemental oxygen (preferably
humidified) should be provided continuously, the patient should not be
unnecessarily disturbed, and experienced personnel capable of cardiopulmonary
resuscitation with appropriate airway equipment should remain with the patient
at all times.
As the physician team is being assembled, simultaneous arrangements should be
made to go to the operating room with adequate O.R. staff. During transfer to
the O.R., humidified oxygen therapy should continue, close monitoring with
attendance by someone proficient in CPR should continue, and the child should
not be disturbed. It is desirable to keep the child in his mother's arms. In
the O.R. direct laryngoscopy should be done. Usually the procedure is done
under general anesthesia. If the diagnosis of acute epiglottitis is
confirmed, an artificial airway should be secured. Preferably, oral
intubation should be performed quickly and then the oral tube should be
replaced by a nasotracheal tube. If endotracheal intubation cannot be
performed quickly and successfully, a surgeon must be prepared to perform a
tracheostomy immediately. Throat culture, epiglottal culture, blood
cultures, and other venipunctures should be deferred until an airway has been
established.
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After the airway is secure, the patient should be moved to Pediatric ICU. The
patient will require careful nursing care with regular suctioning,
chest physical therapy, humidified air and oxygen source, appropriate
restraints, and continuous monitoring. The airway is kept in place generally
24-72 hours. Appropriate antibiotics should be ordered by Pediatrics once the
airway is secure and once indicated cultures are obtained.
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